Notice of No Surprises Act
The purpose of this document is to let you know about your protections from unexpected medical bills. This notice is now required by the federal “No Surprises Act.” Under the law, health care providers, including therapists, need to give clients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services. The act aims to reduce the likelihood that clients may receive a “surprise” medical bill by requiring that providers inform clients of an expected charge for a service before the service is provided.
IMPORTANT: You are not required to sign this form, but will need to sign it to start or continue therapy services. You shouldn’t sign this form if you didn’t have a choice of providers when receiving care. An example would be if a health care provider was assigned to you with no opportunity to make a change. You can choose to get care from a provider or facility in your health plan’s network, which may cost you less.
If you’d like assistance with this document, ask your provider. You’re welcome to take a picture and/or keep a copy of this form for your records.
You are receiving this notice because I (Kelly Wilt, LPC) am not in your health plan’s network. This means that as a provider, I do not have an agreement with your insurance plan. If you’re interested in working with a provider who works directly with your insurance plan, you can contact the number on the back of your health insurance card to find a participating provider.
By choosing to work with me (Kelly Wilt, LPC), an out-of-network provider:
• You may owe the full costs billed for items and services received, if your insurance company does not offer reimbursement.
• Your health plan might not count any of the amount you pay towards your deductible and
out- of-pocket limit. Contact your health plan for more information.
You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services provided by Kelly Wilt, LPC. This includes:
• You have a right to a Good Faith Estimate in writing at least 1 business day before your medical service or item (psychotherapy session). You may ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
• You have the right to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.
Estimate of what you could pay:
Your provider, Kelly Wilt, LPC, is not in network with any insurance company. Kelly is not within your health plan’s network, and you are considered “self-pay.” Some clients submit claims to their insurance company for services provided by out-of-network providers. This may be an option if your insurance plan provides out-of-network coverage. I can make no guarantees of any kind of coverage. However, I am happy to share information with you about how to contact your insurance plan, if you have insurance, and inquire about whether you have out-of-network coverage that may reimburse you for services received while we work together.
The length of a course of psychotherapy varies widely and I do not have an accurate way to estimate your number of sessions up front. However, we can periodically review your care together to assess progress, and it is your right to end services at any time. It is your ethical right to determine your goals for treatment and how long you would like to remain in therapy unless you are pursuing mandatory treatment. The breakdown of my fees is supplied in the Good Faith Estimate for Cost of Services.
► Review your detailed estimate. See separate document entitled Good Faith Estimate for Cost of Services for total cost estimate of what you may be asked to pay, and cost estimate for each item or service.
► Call your health plan. Your plan may have better information about how much of these services are reimbursable. I can supply you with likely procedure (visit) code and provisional diagnosis code to facilitate that call.
► Questions about this notice and estimate? You may contact Kelly Wilt, LPC via email at kelly@kellyjwilt.com or phone: 520-329-3166.
► Questions about your rights? Contact: The U.S. Centers for Medicare & Medicaid Services (CMS) at 1-800-MEDICARE (1-800-633-4227) or visit for more information about your rights under federal law.
Prior authorization or other care management limitations:
Except in an emergency, your health plan may require prior authorization (or other limitations) for certain items and services. This means you may need your plan’s approval that it will cover an item or service before you get them. If prior authorization is required, ask your health plan about what information is necessary to get coverage.
Provider:
Kelly J. Wilt, LPC
705 S 6th Ave, Studio B, Tucson, AZ 85701
P: 520-329-3166 | E: kelly@kellyjwilt.com
(signature portion below included on client E-portal)
With my electronic signature, I am saying that I agree to receive services from Kelly Wilt, LPC.
With my electronic signature, I acknowledge that I am consenting of my own free will and am not being coerced or pressured. I also understand that:
• I may get a bill for the full charges for these items and services or have to pay out-of-network cost-sharing under my health plan.
• I was given a written notice explaining that my provider or facility isn’t in my health plan’s network, the estimated cost of services (The Good Faith Estimate for Cost of Services uploaded to the portal separately and available via hard copy upon request), and what I may owe if I agree to be treated by this provider or practice.
• I got the notice electronically or will request the notice on paper, consistent with my choice.
• I fully and completely understand that some or all amounts I pay might not count toward my health plan’s deductible or out-of-pocket limit.
• I can end this agreement by notifying the provider or facility in writing before getting services.
IMPORTANT: You don’t have to sign this form. I, Kelly Wilt, LPC, will be unable to provide services to you if you elect not to sign it. You can choose to get care from a provider or facility in your health plan’s network.